Male Hypogonadism: Recognizing Low Testosterone Symptoms and Effective Treatments

If you’ve been feeling drained, moody, or just not like yourself-especially if you’re over 40-it might not just be aging. It could be male hypogonadism, a condition where your body doesn’t make enough testosterone. This isn’t rare. Around 4 to 5 million men in the U.S. have it, and the numbers climb with age: half of men over 80 have testosterone levels below the normal range. But here’s the catch: most don’t know it. And even fewer get treated the right way.

What Exactly Is Male Hypogonadism?

Male hypogonadism means your testes aren’t producing enough testosterone. It’s not one condition-it’s two. The first kind, called primary hypogonadism, comes from damaged or underperforming testes. Think genetic issues like Klinefelter syndrome, past mumps infections that hit the testicles, or too much iron in your blood from hemochromatosis. In these cases, your brain sends out more signals (LH and FSH hormones) trying to wake up the testes, but they just won’t respond.

The second kind, secondary hypogonadism, is way more common-making up 85 to 90% of cases. Here, the problem isn’t your testes. It’s your brain. The hypothalamus or pituitary gland isn’t sending the right signals. Obesity is the biggest culprit. Men with a BMI over 30 often have 30 to 50% lower testosterone. Chronic opioid use, pituitary tumors, and even long-term stress can trigger this. The good news? Losing just 10% of your body weight can boost testosterone by 30 to 40% in many cases.

What Are the Real Symptoms?

Symptoms don’t always show up as a sudden loss of muscle or libido. They creep in. You might notice you’re not getting morning erections like you used to. Or that you’re tired all the time, even after a full night’s sleep. You might feel irritable, forgetful, or just emotionally flat. These aren’t just "getting older" signs-they’re biological signals.

Here’s what research shows are the most reliable indicators:

• Decreased spontaneous erections (78% of men with low T report this)
• Reduced or absent nocturnal erections (82% of cases)
• Low sex drive (85% of patients)
• Testicles smaller than 15 mL (measured with a simple tool called an orchidometer)
• Loss of muscle mass (20-30% drop) and increased body fat (10-15% rise)
• Mild anemia (hemoglobin under 13.5 g/dL)
• Thinning bones-up to 33% of long-term untreated men develop osteoporosis

If you’re experiencing three or more of these, it’s worth getting tested. But don’t rely on one blood test. The Endocrine Society says you need two early morning readings (between 8 AM and 11 AM) because testosterone dips after midday. And it has to be measured with mass spectrometry-not the cheaper immunoassay tests, which give false positives up to 20% of the time.

How Is It Diagnosed?

A proper diagnosis isn’t just about checking your testosterone level. It’s a puzzle. Doctors look at:

• Total testosterone (below 300 ng/dL is low)
• Free testosterone (if total is borderline, this matters more-below 65 pg/mL is concerning)
• LH and FSH levels (high = primary; low/normal = secondary)
• Prolactin (elevated levels can mean a pituitary tumor)
• Hematocrit (to check for too many red blood cells)
• PSA (prostate health screening)

Men with testosterone between 250 and 350 ng/dL often need a free testosterone test. Why? Because some men have normal total levels but low bioavailable testosterone due to high sex hormone-binding globulin (SHBG), which is common in older men and those with obesity or diabetes.

Testosterone Replacement Therapy: What Works?

If you’re symptomatic and your labs confirm low testosterone, testosterone replacement therapy (TRT) is the standard. But not all TRT is the same. Here’s how the main options stack up:

Comparison of Testosterone Replacement Therapies

Method	Dosing	Pros	Cons
Topical Gel	5-10 g daily	Steady levels, easy to use	Can transfer to partners/kids; skin irritation; needs 24-hour wait before swimming/showering
Injections (IM)	200-400 mg every 2-4 weeks	Cheap ($30-50/month), effective	Peaks and troughs-mood swings, energy dips; requires injections
Buccal Tablets	30 mg twice daily	No skin contact risk, steady absorption	Gum irritation; frequent dosing; not all insurance covers
Subcutaneous Pellets	150-450 mg every 3-6 months	Stable levels, no daily effort	Surgical insertion ($500-1,000); risk of infection or extrusion
Oral Capsules (Jatenzo)	One capsule with high-fat meal	First oral option with good absorption; no transfer risk	Expensive; requires fatty meal; liver monitoring needed

The best method depends on your life, budget, and comfort. Men who travel often or hate needles often prefer gels or pellets. Those on a tight budget usually choose injections. And if you’re worried about accidentally passing testosterone to your partner or child, oral capsules eliminate that risk entirely.

Who Should Avoid TRT?

TRT isn’t for everyone. The FDA and major medical groups agree: don’t start if you have:

• Prostate cancer (current or untreated)
• Untreated severe heart failure
• Hematocrit over 50% (too many red blood cells)
• Severe sleep apnea

There’s been a lot of fear around TRT and heart health. In 2015, the FDA added a black box warning after some studies showed a 30% spike in heart attacks in men over 65 during the first 90 days of treatment. But newer data tells a different story. A 2022 NIH study of nearly 800 men found no increased heart risk in those on TRT who were properly monitored. In fact, men who stuck with treatment for over a year had a 30% lower death rate than those who didn’t.

The key is monitoring. Hematocrit should be checked every 3 to 6 months. If it rises above 50%, you might need to reduce your dose or have blood drawn (therapeutic phlebotomy). PSA levels should be checked at baseline and again at 3 to 6 months. If PSA rises more than 1.4 ng/mL in a year, further evaluation is needed.

What About Lifestyle Changes?

Before jumping to TRT, especially if you’re overweight, try lifestyle fixes first. Losing 10% of your body weight can raise testosterone levels as much as a low-dose injection. Resistance training-lifting weights 2 to 3 times a week-boosts testosterone naturally. Sleep matters too. Men who get less than 5 hours a night have 15% lower testosterone than those who sleep 7 to 8.

A 2022 UCSF survey found that 65% of men with obesity-related hypogonadism who lost weight were able to stop TRT within 18 months. That’s huge. For men with genetic causes like Klinefelter syndrome, TRT is lifelong. But for many, fixing diet, sleep, and activity levels is the real treatment.

What Happens After You Start?

Most men notice changes within weeks:

• Energy improves in 2 to 3 weeks
• Libido and morning erections return in 4 to 6 weeks
• Muscle strength and mass increase after 3 to 6 months (especially with training)
• Bone density improves after 6 to 12 months

But not everyone responds. About 30% of men have normalized testosterone levels but still feel tired, depressed, or unmotivated. That doesn’t mean TRT failed-it means something else is going on. Depression, sleep apnea, thyroid issues, or chronic stress can mimic low T. Your doctor should check for those too.

Common Side Effects and How to Handle Them

Side effects are real-but manageable:

• Acne (35% of users): Usually mild. Switching gels or lowering dose helps.
• Polycythemia (15%): High red blood cell count. Requires phlebotomy or dose adjustment.
• Testicular shrinkage (25%): Normal with TRT. Your body stops making its own testosterone. If fertility matters, talk to your doctor about hCG or clomiphene instead.
• Mood swings: Often tied to injection peaks and troughs. Switching to gels or pellets helps.

One of the biggest reasons men quit TRT? Cost and hassle. Out-of-pocket, it can run $300 to $500 a month. Insurance often requires proof of symptoms and two low testosterone tests before covering it. Medicare and many private plans now require this documentation.

What’s Next for Treatment?

The field is changing fast. Oral testosterone (Jatenzo) is now FDA-approved, and new drugs called SARMs (selective androgen receptor modulators) are in late-stage trials. These aim to build muscle and improve energy without shutting down natural testosterone production-something current TRT does.

The big unanswered question? Long-term heart safety. The TRAVERSE trial, tracking 5,000 men over five years, is due to finish in 2025. That study will give us the clearest picture yet on whether TRT increases or decreases heart risk.

For now, the message is clear: if you have symptoms and confirmed low testosterone, TRT can change your life. But it’s not a magic pill. It’s a medical treatment that needs monitoring, lifestyle support, and realistic expectations.